Name *

First Name

Last Name

Phone *

(###)

###

####

Date of Birth

MM

DD

YYYY

During virtual sessions, I will: *

use insurance benefits and will be located in Kansas or Missouri.

not use insurance benefits and will be located in one of the states listed above.

Is your concern within Dr. Barreca’s scope of practice? *

I want to work on co-occurring medical and mental health challenges or on specific goals.

I can attend appointments on Thursdays or Fridays.

I am NOT seeking treatment for a condition requiring specialty care (e.g., alcohol or substance dependence, personality disorder, dementia, eating disorders, psychosis, chronic suicidality, and OCD).

I understand that Dr. Barreca does not provide disability assessments.

I understand that virtual CBT is not suitable for crisis intervention or as a replacement for intensive mental health or substance abuse treatment. Please call 911, 988, or go to the emergency room in a crisis or emergency.